The present study aimed to assess the prevalence and determinants of depression, anxiety, and stress among 283 BC patients. Using the DASS-21 scale, we found a prevalence of depression at 46.6%, with 8.5% mild, 16.3% moderate, 7.8% severe, and 14.1% very severe cases. Anxiety prevalence was 56.9%, with 7.8% mild, 17.7% moderate, 12.7% severe, and 18.7% very severe cases. Stress prevalence was 51.9%, with 13.8% classified as mild, 12.0% as moderate, 12.4% as severe, and 13.8% as very severe.
Key determinants included lack of family history of BC in second-degree relatives (depression OR: 1.86, 95% CI: 1.06–3.27; stress OR: 2.15, 95% CI: 1.25–3.68), urban living (depression OR: 3.06, 95% CI: 1.61–5.83; stress OR: 2.19, 95% CI: 1.21–3.96), inadequate perceived income (depression OR: 2.62, 95% CI: 1.52–4.53; stress OR: 1.94, 95% CI: 1.16–3.24), and mastectomy (depression OR: 3.28, 95% CI: 1.88–5.73; stress OR: 1.90, 95% CI: 1.12–3.22).
BC survivors frequently encounter depression, stress, and anxiety, which profoundly influence their quality of life. Understanding the mechanisms driving these mental health conditions is critical for devising effective interventions. Biological mechanisms significantly contribute to these mental health challenges. Cancer and its treatments often provoke systemic inflammation, a process implicated in depression. Research has demonstrated that elevated levels of inflammatory cytokines, such as interleukin-6 and c-reactive protein, correlate with increased depressive symptoms in BC patients21,22. Neurological effects also play a role; cognitive impairments, commonly termed “chemo brain,” arise from chemotherapy and may be associated with heightened stress and anxiety due to their impact on daily functioning23.
Biologically, inflammation underlies behavioral symptoms, with nuclear factor kappa B (NF-κB) and other mediators associating with depressive symptoms post-treatment24. Distinct inflammatory processes contribute to the symptom cluster of depression, fatigue, and sleep disturbances in survivors25. Additionally, covariation with the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system exacerbates pain-depression-fatigue clusters in advanced cases26. At the molecular level, depression and BC share genetic bases and pleiotropic loci, suggesting causal links27. The IL-17/NF-κB pathway also drives BC-related depression28. These biological changes highlight the physiological impact of BC and its management on mental well-being.
Surgical interventions, such as mastectomy, often lead to body image disturbances, which may be linked to depression and reduced self-esteem29. Social mechanisms additionally shape the mental health landscape for survivors. Social support serves as a protective factor, with evidence suggesting that patients with less support networks experience higher levels of depression and anxiety30. Conversely, the financial burden imposed by treatment costs can intensify depression and anxiety, particularly among those in lower socioeconomic brackets31.
The interplay of these mechanisms reveals a complex etiology for depression, stress, and anxiety after BC. Biologically, inflammation and treatment-related changes disrupt physiological homeostasis, while psychologically, the trauma of diagnosis and its aftermath challenge emotional resilience. Socially, support systems and societal pressures either mitigate or exacerbate these effects. This multifaceted nature necessitates a comprehensive approach to care, addressing both the physiological and psychosocial needs of survivors. To contextualize our findings, we compare them with six recent studies: Álvarez-Pardo et al.7 Tsaras et al.8 Benallel et al.9 Breidenbach et al.10 Soqia et al.11 and Guo et al.12. These studies vary in sample size, assessment tools, and cultural settings, providing a broad basis for comparison.
Our study’s prevalence rates are higher than some studies but lower than others. Álvarez-Pardo et al.7 reported 69.18% of 198 BC patients scoring ≥ 8 on the HADS-D (depression), with 10.60% classified as pathological, and 94.44% scoring ≥ 8 on HADS-A (anxiety), far exceeding our rates. Guo et al.12 found 63.6% depression, 60.2% anxiety, and 36.9% stress among 176 metastatic BC (MBC) patients using DASS-21, with depression and anxiety higher than ours, though stress was lower. In contrast, Tsaras et al.8 reported lower rates among 152 patients, 38.2% depression and 32.2% anxiety, using PHQ-2 and GAD-2. Benallel et al.9 found 26% depression in 100 patients via the MINI test, the lowest among these studies. Soqia et al.11 reported 35% depression and 35.6% anxiety in 500 patients using PHQ-2 and GAD-2, also lower than our findings. Breidenbach et al.10 noted that 34.9% of 164 patients had mild to severe depressive symptoms five to six years post-diagnosis, with anxiety scores indicating mild levels, suggesting a lower burden compared to our acute-phase data.
These discrepancies likely stem from the use of differing assessment tools. The DASS-21, used in our study and Guo et al.’s, captures a broad spectrum of symptom severity, potentially inflating prevalence compared to PHQ-2/GAD-2 (Tsaras et al. and Soqia et al.) or MINI (Benallel et al.), which are screening tools with specific cut-offs. HADS, used by Álvarez-Pardo et al., has a lower threshold (≥ 8) for detecting symptoms, explaining its higher rates. Cultural differences across Mexico, Greece, Morocco, Germany, Syria, and China may also influence reporting, with stigma or resilience varying by region, and with Iranian patients potentially internalizing distress.
Our study found no significant association between age and psychological distress. Tsaras et al.8 linked younger age to higher depression and anxiety risk, with rural residents aged 40–59 most affected. Benallel et al.9 reported age 20–40 as a depression risk factor, with no depression in those over 60. Breidenbach et al.10 found women under 50 with higher depression (Coef: 1.17) and anxiety (Coef: 1.08) in linear regression. Soqia et al.11 noted that younger age (≤ 45) increased depression (OR: 1.485, 95% CI: 1.012–2.179) and anxiety (OR: 1.646, 95% CI: 1.125–2.408). On the other hand, Guo et al.12 and Aggeli et al.32 found no age effect. Our lack of age association may reflect a narrow age range or cultural factors mitigating age-related distress in our predominantly middle-aged sample.
With 95.4% of our participants married, we found no association with marital status. Tsaras et al.8 linked marital status to depression and anxiety, though specifics were unclear. Soqia et al.11 found divorced (OR: 6.031, 95% CI: 1.1751–23.151) and widowed (OR: 3.300, 95% CI: 1.237–8.803) women with higher depression, and widowed with higher anxiety (OR: 2.742, 95% CI: 1.075–6.993). Guo et al.12 identified poor marriage quality as a predictor of depression, anxiety, and stress. Álvarez-Pardo et al.7 found single women with higher anxiety scores (12.54 vs. 11.57), while Vahdaninia et al.33 found being single as a protective factor against depression. Our high marriage rate may have masked variability, unlike studies with diverse marital statuses. This may reflect Iran’s exceptionally high marriage rate (95.4%) limiting variability, and cultural normalization of midlife health challenges in our 40-44yo dominant subgroup.
Education beyond high school (47.0%) was not a determinant in our study. Tsaras et al.8 associated lower education with higher depression and anxiety risk. Breidenbach et al.10 found that university education is protective against depression (Coef: -1.15). Other studies found no link9,11,12,32. Educational differences across populations or cultural valuation of education may explain these inconsistencies. Inadequate income increased depression (OR: 2.62) and stress (OR: 1.94) in our study, similar to Sebro et al.‘s findings, which revealed that lower-income BC patients were at higher risk for depression in Ethiopia13. Guo et al.12 also found income predictive of depression. Tsaras et al.8 and others did not report income effects, possibly due to differing socioeconomic contexts or healthcare access32as Benallel et al.‘s9 insured sample showed no income impact.
Notably, we found no family history of BC in second-degree relatives linked to higher depression (OR: 1.86) and stress (OR: 2.15); however, Álvarez-Pardo et al.7 reported no significant difference in these outcomes (depression: 8.61 vs. 8.01; anxiety: 12.12 vs. 11.68). Other studies reported no association. This may reflect greater shock or isolation in patients without familial BC experience, a factor less explored elsewhere. Contrary to assumptions about genetic risk buffering psychological impact, patients without second-degree family histories showed significantly higher depression. This suggests that familial cancer exposure may foster psychological preparedness, whereas those lacking this background experience greater diagnostic shock and isolation.
Mastectomy increased depression (OR: 3.28) and stress (OR: 1.90) compared to breast-conserving surgery in our study. Breidenbach et al.10 linked mastectomy to higher anxiety (Coef: 0.91). Álvarez-Pardo et al.7 and Cáceres et al.34 found no difference in scores (depression: 8.18 vs. 8.15, anxiety: 12.08 vs. 11.62 in Álvarez-Pardo et al.’s; and 10.29 ± 7.83 vs. 10.95 ± 8.09 Beck Depression Inventory score in Cáceres et al.’s). Body image concerns or counseling differences may drive our findings, contrasting with Álvarez-Pardo’s null result.
Psychosocially, mastectomy induces body image disturbances, feelings of incompleteness, and insecurity, heightening anxiety and depression35,36. Cognitive attitudes like helplessness/hopelessness, global stress perceptions, intrusive cancer-related thoughts, financial difficulties, and neuroticism amplify symptoms37,38. Lack of social support and poor coping exacerbate distress, though interventions like pre-surgical psychological support and breast reconstruction aid adaptation39.
Urban living increased depression (OR: 3.06) and stress (OR: 2.19) in our study, unlike Tsaras et al.8where rural residents had higher risks (depression OR: 2.6; anxiety OR: 3.8). Urban stressors (e.g., isolation, cost) versus rural healthcare access issues may explain this divergence. We propose this stems from urban Iran’s ‘double burden’: financial pressures from treatment costs in cities, compounded by reduced communal support in anonymized urban environments. This contrasts with rural settings where traditional support networks remain intact despite healthcare access challenges.
Employment was not a determinant in our study (73.9% jobless). Álvarez-Pardo et al.7 found unemployed women with lower depression scores (7.89 vs. 8.61), while Guo et al.12 found working status predictive of depression. Our high unemployment rate may limit the detection of variability.
Inconsistencies arise from multiple factors. Assessment tools variation in sensitivity, and cultural attitude differences toward mental health, and BC across nations affect prevalence and reporting. Sample characteristics, such as our age distribution, marital status, non-metastatic patients versus Guo et al.’s metastatic patients, and unexplored factors like other comorbidities or cancer progression may also influence outcomes.
Implications
In clinics, the 46.6% depression rate, 56.9% anxiety rate, and 51.9% stress rate signal a clear need to check patients’ mental health regularly. Nurses and oncologists can use the DASS-21 questionnaire during routine follow-ups, as it is quick and has already been proven effective in our study, with a good Cronbach’s alpha reliability. If patients score high, they can be referred to a counselor or social worker already on the hospital team. For rural patients or those who cannot travel, phone check-ins can serve as a substitute for in-person visits, using the same DASS-21 questions to identify issues. This helps keep costs down while identifying problems early.
For public health, our data shows urban residents have higher odds of depression and stress, as do those with inadequate perceived income and mastectomy patients. Local health offices can set up free peer support groups in cities, targeting these groups. For example, a weekly meet-up at a community center can let mastectomy patients share tips on coping with body image changes. Pamphlets with stress management advice, such as breathing exercises, can be distributed at clinics or mailed to low-income patients, leveraging existing mail systems. These steps utilize resources already available, thereby avoiding significant expenses.
Additionally, in clinical and population-based settings, non-pharmacological interventions offer practical, cost-effective ways to manage depression, stress, and anxiety in BC patients. Based on evidence from multiple studies, several strategies stand out for their accessibility and impact. In clinics, physical activity is a straightforward option. A meta-analysis of 26 studies with 2105 participants showed improved quality of life (Hedges’ g = 0.67) and reduced anxiety (Hedges’ g = -0.28) in BC survivors. Clinicians can recommend that patients walk for 30 min most days or join a low-cost yoga class, which requires no special equipment and can be done at home or in a group40. Music therapy also proves effective, with 13 studies involving 1326 patients showing reductions in anxiety (SMD = -0.82) and depression (SMD = -0.76)41. Patients can listen to pre-recorded tracks for 20–30 min daily, using a smartphone or inexpensive CD player, guided by staff to choose calming selections.
Mindfulness-based interventions (MBIs), evaluated in 19 studies involving 2139 participants, were found to lower depression (g = 0.48)42. Nurses can teach simple breathing exercises during appointments, encouraging patients to practice them for 10 min daily at home. Art therapy, assessed in 9 studies with 754 patients, reduced anxiety and depression (SMD = -0.48)43. Clinics can provide paper and pencils for patients to draw during wait times or sessions. Cognitive behavioral therapy (CBT), reviewed in 16 studies, consistently decreased depression and anxiety scores (p < 0.05 in 14 studies)44. Staff can deliver brief CBT techniques in one-on-one talks or use free online tools to guide patients remotely. To make these work, clinics should ask patients what they can realistically do and teach them how to start independently. Public programs can partner with local gyms or charities for space and resources. Tracking progress with quick surveys ensures adjustments if something is not helping.
Future research directions
Future research can delve deeper into these findings by addressing specific, practical questions. A study could track BC patients over a year, using DASS-21 scores every 2–3 months to see when depression peaks. Another study could test if a 10-minute phone counseling session monthly improved mental well-being comparing it to no calls. Researchers should also explore why patients without a family history of BC in second-degree relatives face higher depression and stress odds; is it shock from an unexpected diagnosis? These focused studies can guide clinics and health officials without needing massive funding.
Limitations
This study has its limitations, including its cross-sectional design, which prevents establishing causality. Additionally, unmeasured confounding variables, such as social support or other comorbidities, could influence the results. The study also did not explore the impact of treatment duration or recurrence on psychological distress. Third, our inclusion criteria requiring literacy and internet/device access may have excluded vulnerable subpopulations (e.g., elderly, low-income, or rural patients with limited digital access). This could underestimate true prevalence in these groups and limit generalizability. Future research should develop and validate telephone-administered versions of instruments like DASS-21 for inclusive sampling. Finally, previous psychiatric history (e.g., pre-existing diagnoses of depression, anxiety disorders, or other mental health conditions) was not assessed in this study. This data was unavailable in the cancer registry and not collected via our questionnaire. Consequently, we cannot determine whether the reported symptoms of depression, anxiety, and stress were solely attributable to the BC diagnosis or its treatment, or if they represent exacerbations of pre-existing conditions. While this is a common limitation in cross-sectional prevalence studies focusing on the cancer population ‘at a glance,’ it restricts causal inferences regarding BC as the sole originator of the psychological distress observed.